Q85.89 Insurance Policy Changes

ICD-10 Q85.89 is officially defined as "Other phakomatoses, not elsewhere classified." code Q85.89 is referenced in 5 tracked payer policy changes from Aetna and Blue Cross & Blue Shield of Mississippi. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code Q85.89 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Identified Oct 5, 2026Medium impact
Mammography (CPB 0584, reviewed 2026-09-10)
Annual screening mammography is medically necessary for women aged 40 and older as a preventive service, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, whether or not they have preventive benefits. AI-based mammography, contrast-enhanced mammography for members who do not meet the medical necessity criteria, and screening mammography in men outside the listed indications are considered experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Mammography (CPB 0584, reviewed 2025-09-09)
Aetna considers annual screening mammography medically necessary as a preventive service for women aged 40 and older, and for women under 40 who are judged to be at high risk, such as BRCA1 or BRCA2 mutation carriers and women meeting the other listed risk criteria. Diagnostic mammography is covered for members with signs or symptoms of breast disease or a history of breast cancer, regardless of whether the member has preventive benefits. Digital mammography and digital breast tomosynthesis are acceptable alternatives to film and standard 2D mammography, computer-aided detection is a medically necessary adjunct, and contrast-enhanced mammography is covered only for high-risk members who meet breast MRI criteria but have a documented contraindication, intolerance, or lack of access.
Aetna · Identified Aug 14, 2026Medium impact
Double Balloon Enteroscopy (CPB 0737, reviewed 2025-11-13)
Aetna considers double balloon enteroscopy medically necessary for dilation of small bowel strictures in Crohn's disease, evaluating suspected small bowel malignancies, evaluating the colon after incomplete colonoscopy, suspected Meckel's diverticulum with an indefinite imaging work-up, obscure GI bleeding with objective evidence of recurrent bleeding, removing entrapped foreign bodies in the small bowel, removing large polyps greater than 10 mm in Peutz-Jeghers syndrome, GI bleeding when the small intestine is the source, and use with ERCP in individuals with surgically altered upper GI anatomy. Aetna considers double balloon enteroscopy experimental, investigational or unproven for other indications, including detection of small bowel neuroendocrine tumors, small bowel varices, treatment of intussusception, treatment of angioectasia (type 1 small bowel vascular lesions), and treatment of post-operative bile leakage after hepaticojejunostomy. Combined double balloon enteroscopy and endoscopic ultrasound for evaluation of Crohn's disease is also considered experimental, investigational or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
Wireless capsule endoscopy of the small bowel is medically necessary for suspected small bowel bleeding after prior inconclusive upper and lower GI endoscopic studies performed during the current episode of illness, for initial diagnosis of suspected Crohn disease without evidence of disease on small bowel follow-through and upper and lower endoscopy, for an established Crohn disease diagnosis when there are unexpected changes in disease course or response to treatment, and for small bowel surveillance in hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome. Other uses are investigational, including evaluating the extent of known Crohn disease or ulcerative colitis, the esophagus, the colon including colonic polyps or colon cancer, other GI diseases not presenting with GI bleeding, initial evaluation of acute upper GI bleeding, lower GI bleeding with major risks for colonoscopy, and patients following an incomplete colonoscopy. The patency capsule is investigational, and magnetic capsule endoscopy is investigational for unexplained upper abdominal complaints and all other indications.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Genetic testing for PTEN may be considered medically necessary to confirm a diagnosis when an individual has clinical signs of a PTEN hamartoma tumor syndrome. Targeted testing for a PTEN familial variant may be considered medically necessary in a first-degree relative of a proband with a known PTEN pathogenic variant, and all other genetic testing for PTEN is considered investigational. The 07/31/2026 update changed the policy description and removed ICD-9 diagnosis codes, and the policy statements are unchanged.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code Q85.89?

There are 5 tracked policy changes affecting code Q85.89, including updates from Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code Q85.89?

Payers that have issued tracked updates for code Q85.89 include: Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code Q85.89 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code Q85.89. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code Q85.89?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Mammography (CPB 0584, reviewed 2026-09-10)

Mammography (CPB 0584, reviewed 2025-09-09)

Double Balloon Enteroscopy (CPB 0737, reviewed 2025-11-13)

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

Genetic Testing for PTEN Hamartoma Tumor Syndrome

What insurance policy changes affect code Q85.89?

Which payers have updated policy for code Q85.89?

How do I get notified when code Q85.89 policy changes?

Why do payers change policies for code Q85.89?